Surgical Aspects of Infertility
Michael P. Diamond
Table Of Contents
Michael P. Diamond, MD
SURGICAL ASPECTS OF INFERTILITY: NEW PRINCIPLES
TREATMENT OF TUBOPERITONEAL DISEASE
TUBAL ECTOPIC PREGNANCY
OVARIAN WEDGE RESECTION
TREATMENT OF UTERINE PATHOLOGY
ALTERNATIVES TO SURGICAL TREATMENT
COMPLICATIONS OF ENDOSCOPIC SURGICAL PROCEDURES
Infertility has been estimated to affect approximately 15% of couples attempting to conceive in the United States.1 Its consequences are manifested in many ways in our society, including the monetary costs of its investigation, diagnosis, and treatment as well as the psychosocial stresses2,3 it imposes on this portion of our population.
Causes of infertility potentially amenable to surgical treatment include tuboperitoneal disease and abnormalities of the uterine cavity. These are estimated to account either alone or in part for the infertility of 40% of couples.4 Anatomic findings within this broad category include adhesions, implants of endometriosis, and partial or complete tubal obstruction. Their most common causes are prior surgery, endometriosis, and infection (either clinically recognized or unrecognized). With regard to abnormalities of the uterine cavity, some conditions such as Asherman's syndrome are surgically correctable causes of infertility. The contribution to the development of infertility of other surgically correctable pathologic findings, such as uterine septa or intracavitary myomas, is variable and is thought to depend on the specific characteristics of each lesion.
Over the past several decades, new techniques and instruments have been introduced that have the potential of restructuring the performance of reproductive pelvic surgery. First was the recognition of a role of “microsurgery” in the performance of these procedures. The second, which is continuing to evolve and is less well established, is endoscopic surgery as an alternative to laparotomy. Third is the choice for tissue incision or excision with the use of electrosurgery, sharp dissection, or lasers. A proper role for the latter topic also continues to be evaluated, but its application appears to have peaked because many surgeons are reducing their use of lasers.
Therefore, more than previously, the role of surgical aspects of infertility is undergoing re-examination. This review attempts to describe considerations in the decision-making process in regard to whether, when, and how to perform reproductive pelvic surgery. An introduction to each of these advances is given, followed by an evaluation of individual surgical operations. Direct comparisons of surgical series conducted under varying conditions are not entirely appropriate, but they do allow guidance for the aforementioned questions. The series included in the tables were selected from the literature; more complete listings are described in the references. Additionally, pregnancy outcome in many of the reports had to be modified based on the information provided to conform to the subset desired (e.g. conception rates versus term deliveries). Finally, it should be recognized that the assisted reproductive technologies (ART) can also be considered an alternative to surgical repair in some patients with extensive tuboperitoneal disease. The appropriate applications of surgical treatment via laparotomy, laparoscopy, or ART vary among patients and are likely to be modified as advances are made in these areas. (A discussion of the role of ART in the treatment of tuboperitoneal-based infertility is beyond the context of this chapter; the reader is referred to the ART section of this series.)
|SURGICAL ASPECTS OF INFERTILITY: NEW PRINCIPLES|
Use of microsurgery in the performance of reproductive pelvic procedures was initially described by Swolin in 1967.5 Microsurgery in this context includes, but is not limited to, the use of magnification. The advantage of magnification is that it allows close inspection so as to improve the ability to discriminate between normal and pathologic tissue and to allow the use of fine-caliber microsurgical instruments and sutures.6 Other tenets of gynecologic microsurgery include achieving meticulous hemostasis, minimizing tissue handling, preventing desiccation of tissue, avoiding introduction of foreign bodies (e.g. talc) into the operative field, using fine suture material of low tissue reactivity, and precisely reapproximating tissue planes.6,7
Although most of these tenets are probably correct, one that may be incorrect is the value of precise tissue approximation. In animal studies, suture closure of the ovarian cortex was associated with greater, not lesser, adhesion development.8 It remains unclear whether this represents a foreign body reaction to the sutures, a response to the increased tissue handling required to place the sutures, a consequence of tissue anoxia, or a combination of all these factors. Regardless of the actual mechanism, this report8 and others like it appeared to call into question the routine “reperitonealization” of all peritoneal and serosal defects, particularly those that do not protect vital structures. Finally, important corollaries exist to two of the tenets of microsurgery: achieving meticulous hemostasis and minimizing tissue handling. Although the presence of blood at the operative site increases postoperative adhesion development, it is important that hemostasis be achieved in a manner that devitalizes as little surrounding tissue as possible. When possible, the size of pedicles should be minimized and use of electrosurgery should be restricted to the actual bleeding site. With regard to tissue handling, manipulation of structures is required to achieve exposure and perform the procedure. However, tissue damage can often be minimized by the use of atraumatic graspers, moist (not dry) pads, and, when feasible, grasping of tissue structures to be excised.
A less recognized, yet extremely important, characteristic affecting the results of microsurgical gynecological procedures is the experience of the surgeon. Oelsner and coworkers9 examined this issue directly, assessing microsurgical skill as a function of the number of isthmic reanastomoses performed on the rabbit fallopian tube. In evaluations of pregnancy rates, nidation index, and scanning electron microscopy sections of the anastomotic sites, they demonstrated a positive correlation between increasing experience and successful surgical outcome. A second report indirectly addressed this issue. DeCherney and associates10 examined the failure rate of microsurgical tubal anastomoses, and noted that, compared with an initial success rate of approximately 50%, pregnancy outcome improved with experience, reaching a plateau at a rate of approximately 70%.
Direct comparison of clinical outcome of surgical procedures performed by macrosurgery versus microsurgery is difficult because of differences in the procedures performed, in the extent of coexistent pelvic disease, and in chronology. Introduction of different centers and surgeons further complicates such comparisons. These observations notwithstanding, several investigators have conducted such examinations and have found trends favoring successful pregnancy with microsurgery.11,12,13,14
Many investigators have advocated adoption of the principles of gynecologic microsurgery7,15,16,17,18,19; its use and efficacy are described in subsequent sections of this chapter dealing with specific operative procedures. Use of these principles, however, should not be limited to the microsurgeon, but should be employed by all surgeons performing pelvic operations so as to minimize postsurgical development of pelvic adhesive disease.
DeCherney, in 1985, predicted that “the obituary of laparotomy for pelvic reconstructive surgery has been written; it is only its publication that remains.”20,21 More than 15 years later, this prophesy remains almost as controversial as when it was written. Clearly, a wide variety of the reproductive pelvic surgical procedures performed at laparotomy can also be performed at laparoscopy or hysteroscopy. This list includes adhesiolysis, fimbrioplasty, neosalpingostomy, linear salpingostomy, fulguration/vaporization of endometriosis, transection of uterosacral ligaments, drainage of ovarian cysts, and removal of uterine septa. Later sections of this review describe the clinical efficacies of these procedures as performed by laparotomy or by laparoscopy/hysteroscopy. The reader is also referred to recent reviews for more in-depth considerations.
Application of Lasers
Several investigators have examined the application of lasers for the performance of reproductive pelvic surgical procedures, both at laparotomy and in endoscopic procedure. The most frequently used type to date is the carbon dioxide (CO2) laser;22 others now in use include the argon, the potassium titanyl phosphate (KTP-532), and the neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers. A comparison of characteristics of these different types of lasers is made in Table 1. Efficacy of their use is described for individual procedures. In general, there has been no evidence that use of a laser per se results in a greater reduction of adhesions or improvement in pregnancy outcome, compared with other surgical modalities.23,24,25 However, individual surgeons, based on their own experience, equipment availability, and preference, may find use of a particular laser to be most advantageous for the performance of these procedures.26,27,28,29
|TREATMENT OF TUBOPERITONEAL DISEASE|
Pelvic adhesions have been identified as a major contributing cause of infertility. In these patients, goals of reconstructive pelvic surgery include lysis of adhesions that interfere with physiologic processes of ovum release, pickup, and transport and minimal subsequent development of postoperative adhesions.
Classification of the type or extent of pelvic adhesion has been described in several previous reports.30,31,32,33,34,35 Jessen34 described an improved pregnancy rate in the presence of low-grade compared with high-grade adhesions (64% versus 22%, respectively). Subsequently, Hulka and colleagues31 classified the extent and type of adnexal adhesions, and later the same authors demonstrated their prognostic value.33 Pregnancy was more likely to occur when more than 50% of the ovary was visible and when adhesions were filmy and avascular, rather than dense and vascular. Similarly, Caspi and coworkers32 demonstrated that pregnancy rates were higher in association with fine, avascular as opposed to fibrous, coarse adhesions. In these reports, as well as those of Young and associates,35 the significance of adhesions (as assessed by the pregnancy rate) was clouded by the classification systems, which also relied on tubal patency (and performance of fimbrioplasties and salpingostomies).
The report that has most closely assessed the role of periadnexal adhesions alone on pregnancy outcome is that of Bronson and Wallach.30 They scored adhesions at varying locations (right and left ovaries, fallopian tubes, pelvic sidewalls, broad ligaments, cul-de-sac, and rectosigmoid) and observed that pregnancy rates were lower among women with high adhesion scores, although the difference was not significant. Importantly, however, in these studies looking at pregnancy outcome,30,31,32,33,34,35 the incidence, extent, and severity of adhesions at the time the women were trying to conceive is not known, nor were there extensive controls for other factors that may contribute to infertility.
Adhesiolysis has traditionally been performed by sharp dissection or electrosurgery; more recently, it has also been performed using the CO2 and argon lasers36,37 and linear cutters. A comparison of pregnancy outcome after adhesiolysis at laparotomy and at laparoscopy with various techniques is shown in Table 2.38,39,40,41,42,43,44,45,46 In general, the use of microsurgical techniques has led to a trend for improvement in pregnancy outcome after adhesiolysis. As shown, in women in whom there is no distal tubal obstruction, adhesiolysis can be expected to lead to pregnancy in 50% to 60% of cases. Use of the CO2 laser, compared with nonlaser techniques, has not resulted in improvements in pregnancy outcome,43 nor has it resulted in consistent reductions in the adhesions observed at the time of second-look laparoscopy.47 Consistent with these findings is the report of Pittaway and colleagues,48 which described no reduction in postoperative intraperitoneal adhesion formation in rabbits and rats, respectively, with the CO2 laser as compared to electrocautery.48a
As a result of technological advances, it is now possible to perform adhesiolysis (and other reproductive pelvic surgical procedures) at laparoscopy. Although relatively minor procedures can be performed by most laparoscopists, treatment of more extensive disease requires advanced training and experience. In experienced hands, laparoscopic treatment (usually involving multiple-puncture techniques) appears to yield results similar to those achieved with laparotomy.45,46 However, no well-controlled studies examining this issue have been performed.
Adhesion reformation after reproductive pelvic surgery occurs frequently, even with the use of microsurgical techniques and surgical adjuvants.49 Although adhesion reformation was defined in one report49 as a redevelopment of adhesions at sites that were subjected to adhesiolysis at the time of the initial procedure, other authors have used the same term to refer to different situations, thereby creating considerable confusion in the literature.50 To provide a common terminology for comparison of efficacy of different techniques and adjuvants in reducing postoperative adhesions, a classification system has been proposed that takes into consideration the presence or absence of adhesions initially, and whether a surgical procedure other than adhesiolysis was performed at that site (Table 3). Importantly, this classification also includes the concept of de novo adhesion reformation (the development of adhesions, observed at the time of the second-look procedure, for which adhesiolysis was not performed at the time of the initial procedure). As shown in Table 4, de novo adhesion formation can be a frequent problem after microsurgery performed at laparotomy, occurring in 58% of available ovaries and at almost one third of all available sites in those affected.51
*Frequency of de novo adhesion identified at early second-look laparoscopy at sites throughout the pelvis after reproductive pelvic surgical procedures performed at laparotomy.
(Diamond MP: Adhesion prevention. In Gershenson DM, DeCherney AH, Curry SL (eds): Operative Gynecology, Chap 8. pp 147---158. Philadelphia, WB Saunders Company, 1993)
It had been suggested, anecdotally, that procedures performed by laparoscopy might be less likely to be followed by the postoperative development of pelvic adhesions. Theorized explanations included reductions in tissue drying, tissue manipulation, and introduction of foreign materials and lack of packing of bowel. However, in a multicenter study evaluating adhesion reformation at a second-look pro-cedure after laparoscopic adhesiolysis, adhesion reformation was identified in 66 of 68 subjects (97%).52 However, laparoscopic adhesiolysis was able to reduce significantly the extent of pelvic adhesions, to approximately half of what was present initially. De novo adhesion formation occurred in only 8 (12%) of these 68 women, and in 11 (23%) of 47 available sites in those affected. This suggests that de novo adhesion formation (not adhesion reformation) may occur less frequently after laparoscopic surgery, but confirmation of this hypothesis will require properly controlled studies.
Surgical adjuvants have been used frequently after adhesiolysis and other types of intra-abdominal reproductive pelvic surgical procedures. The rationale for use of adjuvants is to minimize development of postoperative adhesions and to maximize maintenance of tubal patency after the initial surgical procedure. As shown in Table 5, a variety of agents have been used for this purpose. This use has been described in detail in several reviews.15,53,54,55,56,57,58,59,60,61
Despite application of microsurgical technique and use of surgical adjuvants by experienced surgeons, the development of postoperative adhesions is an all too frequent occurrence.62,63,64,65,66,67,68,69 Currently, no serum marker or scanning technique is consistently able to identify adhesions, and a repeat operative procedure is required for evaluation. As shown in Table 6, pelvic adhesions were identified at the time of second-look laparoscopy in 55% to 100% of women who had undergone reproductive pelvic surgical procedures. Such adhesions represent both adhesion reformation and de novo adhesion formation.70 Inasmuch as such adhesions might impair the ability to conceive, there appears to be room for improvement in preventing postoperative adhesion development. In a poll of the members of the Society of Reproductive Surgeons, Holtz71 reported widespread use of agents for this purpose throughout the United States, including perioperative antibiotics, corticosteroids, and antihistamines and intraoperative instillation of 32% dextran 70 (Hyskon). The literature is replete with conflicting results for most adjuvants, and their efficacy is not well established. A potential explanation is differences in the pathologic conditions being treated.
Three groups have demonstrated fundamental differences between adhesion formation and adhesion reformation in animal models. Holtz and associates72,73 described reduction in adhesion formation with 32% dextran 70, but a similar inhibition of adhesion reformation could not be achieved with higher doses of dextran. Similarly, Elkins and coworkers74,75 observed a greater extent of adhesion reformation than adhesion formation after dextran treatment. Finally, Diamond and associates76,77 compared adhesion formation and reformation models and noted a greater extent of adhesions in the latter.
In the survey of the members of the Society of Reproductive Surgeons, Holtz71 reported that 45% performed second-look laparoscopy on occasion. There are several benefits of second-look procedures after reconstructive pelvic surgery. Such procedures allow for assessment of the adnexal disease, allowing patients to assess their potential for fertility and plan accordingly. Second, they provide an opportunity to lyse adhesions that have reformed (or to perform additional procedures as needed, such as vaporization of endometriosis or deagglutination of fimbria). Third, based on the previously established principles that pelvic adhesions can cause infertility30,32,45 and that lysis of adhesions is associated with pregnancy establishment in many women,30,32,45 performance of second-look laparoscopy may improve the pregnancy rate after reproductive pelvic surgery, although this theoretical improvement has yet to be substantiated. Trimbos-Kemper and colleagues67 and Jansen78 reported that second-look laparoscopy was associated with a significant reduction in the subsequent observation of permanent pelvic adhesions, but the pregnancy rate was not improved. Trimbos-Kemper and coworkers67 did, however, note a reduction in the occurrence of ectopic pregnancies after salpingostomies in women who underwent early second-look laparoscopy. Finally, for the benefit of the surgeon, performance of second-look laparoscopy allows for feedback as to the surgical success of the procedures previously performed.
If second-look laparoscopy is to be performed, Swolin79 recommended that it be done early (6 to 8 weeks) to improve the possibility of lysis of postoperative adhesions. Subsequently, Raj and Hulka80 examined second-look laparoscopies performed up to 2 years after the initial procedure and demonstrated that bleeding was more common if the procedure was performed after 12 weeks or before 2 weeks. In the former case, bleeding was attributed to increased density and vascularity of the adhesions; in the latter, bleeding was attributed to granulation tissue. Between 2 and 12 weeks, the adhesions were filmy and more amenable to lysis. Surrey and Friedman65 observed that attempted adhesiolysis 6 months after the initial procedure was associated with more dense and vascular adhesions than were present at 6 to 8 weeks. DeCherney and Mezer63 also compared early (4 to 16 weeks) versus late (approximately 18 months) second-look laparoscopy; in the former group, 60% of patients had thicker neovascular adhesions. Finally, Daniell and Pittaway,68 McLaughlin,64 and Diamond and coworkers62 have also observed that adhesions at “early” second-look laparoscopy are more likely to be filmy and avascular, making them more susceptible to easy lysis. However, in multiple studies involving an opportunity for early second-look laparoscopy after the initial surgical procedure, there appeared to be no difference in the type (filmy and avascular versus dense and vascular) of adhesions observed at second-look laparoscopy.47,80a,80b,80c
Distal Tubal Obstruction: Complete
The surgical treatment of complete fimbrial occlusion is a neosalpingostomy: the creation of a new tubal ostia. Performance of neosalpingostomy is associated with a subsequent tubal patency rate of approximately 90% to 95%;81 however, pregnancy rates are only about 30% (Table 7).82,83,84,85,86,87,88,89 With prolonged follow-up of 5 years, pregnancy rates of 42% have been achieved.90 Comparison of series of macrosurgical and microsurgical neosalpingostomies fails to demonstrate an advantage of microsurgery. Again, however, a study designed to directly compare the two techniques has not been performed. Both Mage and Bruhat86 and Tulandi and Vilos87 have compared microsurgical neosalpingostomies performed by laser and nonlaser techniques. Each group reported no difference in pregnancy outcome.
Performance of neosalpingostomy at laparoscopy has been reported by several groups.36,40,89,91 Pregnancy results appear to be less than for comparable reports at laparotomy. However, the patient selection for neosalpingostomy at laparoscopy includes women who refuse laparotomy, and therefore the patient populations may not be comparable.
The relatively poor pregnancy outcome after neosalpingostomy, compared with other types of reconstructive pelvic surgical procedures, and despite re-establishment of tubal patency in most patients, is thought to be caused in large part by intraluminal tubal pathology. The presence of coexistent pelvic adhesions, which restrict tubal motility and ovum capture, has also been implicated in reduction of successful pregnancy outcome.
Intraluminal tubal abnormalities primarily represent the pathologic sequelae of infection, although changes can also occur in response to endometriosis or exposure to diethylstilbestrol (DES)92 in utero. Chronic postinfectious histologic intraluminal changes observed include the presence of intraluminal adhesions, loss of villous folds, and ciliary destruction. It is unclear whether the latter is caused by the increased hydrostatic pressure resulting from tubal occlusion or is an effect of the infectious process itself.
Classifications of pregnancy outcome after neosalpingostomy have been based on intratubal and extratubal characteristics. Screening for these characteristics, to assess the likelihood of establishing a pregnancy, is performed by hysterosalpingography and laparoscopy, respectively. Rock and colleagues93 developed a classification of distal tubal obstruction based on hydrosalpinx diameter, rugal pattern, extent of fimbrial damage, and extent of coexistent pelvic adhesions (Table 8); they were able to demonstrate a deterioration in outcome as the extent of disease progressed from mild to moderate to severe.
More recently, Boer-Meisel and coworkers85 used a system for classification of hydrosalpinges to establish intrauterine pregnancy rates with good, intermediate, and poor outcome (77%, 21%, and 3%, respectively). The factors used for this analysis were the nature and extent of pelvic adhesions, the hydrosalpinx diameter, the hydrosalpinx tubal wall thickness, and the macroscopic assessment of the condition of the endosalpinx.
After surgical correction of complete distal tubal obstruction, the most likely time to conceive is more than 1 year after the surgical procedure.42,82,94 This time lag is thought to be required because of the tubal mucosa needs to regenerate after the damage that occurred while a hydrosalpinx was present. According to two preliminary descriptions, the surgery-to-conception interval after neosalpingostomy can be reduced if the procedure is performed with the CO2 laser;81,95 however, no further substantiation of this possibility has been forthcoming.
New diagnostic techniques to predict the likelihood of establishing a pregnancy after distal tubal obstruction are tuboscopy and fimbrial biopsy. In the former technique, a narrow-diameter scope or fiber is passed into the fimbrial ostium at the time of laparoscopy or laparotomy, or through the tubal cornua, which is visualized hysteroscopically. This allows direct examination of the intraluminal anatomy and identification of adhesions, areas of deciliation, and flattening of the mucosal folds. In early studies with this technique, the findings correlated significantly with subsequent pregnancy outcomes and therefore may be helpful in referral of patients for tubal repair and ART.96,97,98,99,100,101 This may particularly be the case as technologies for transcornual viewing are improved, making this an office procedure. Therefore, tuboscopy may be beneficial in preoperative patient screening. Regarding fimbrial biopsy, Donnez and associates42 showed that the ciliation index obtained on microbiopsy was impaired in the presence of tubal disease and that the index was predictive of subsequent pregnancy outcome.
Distal Tubal Obstruction: Incomplete
Comparison of outcome after surgical treatment of incomplete distal tubal obstruction is difficult because of the diversity of pathology it may represent. The clinical findings range from slight fimbrial agglutination to peritubal bands to fimbrial phimosis causing near-total occlusion and can occur in association with varying degrees of pelvic adhesions. Therefore, analysis of efficacy of treatment of incomplete distal tubal obstruction must be carefully scrutinized. A summary of pregnancy outcomes after such procedures is shown in Table 9.102 These results tend to be better than those for complete distal obstruction, probably reflecting less intratubal damage. Although follow-up is limited, surgical treatments with the CO2,103 argon,36 KTP-532,104 and Nd:YAG105 lasers have been described; their use has not been associated with improved pregnancy rates. Few series describe pregnancy outcome after laparoscopic treatment of incomplete fimbrial obstruction; therefore, analysis of the relative efficacies of laparoscopy and laparotomy as methods of treatment is premature.
Endometriosis has been reported to contribute to infertility, not only by causing mechanical barriers to sperm-oocyte interaction but by a diverse group of other mechanisms as well. These alternative mechanisms include effects on ovarian steroidogenesis, ovulation, tubal ovum pickup, tubal motility, tubal ciliary action, and peritoneal macrophage activity. In part, these effects are thought to be mediated by prostaglandins.
Various systems have been used to classify endometriosis.106,107,108,109 Most early reports used the Acosta classification,106 grouping cases into mild, moderate, and severe stages based on the location and extent of endometriosis and the degree of pelvic adhesions. Classifications by Kistner and associates107 and by the American Fertility Society (now called the American Society for Reproductive Medicine) were subsequently established,108 followed by a revised classification by the latter group in 1985,109 which is pictured in Figure 1. Use of classifications is advantageous because the scoring confers an extent of disease, allowing comparison of reports from different investigators and centers.
The relative efficacy of different methods of treating endometriosis is not well defined; in some reports, pregnancy outcome was no different with observant management than it was with medical or surgical treatment.110,111 However, a recent large, well-designed, multicenter trial did identify improvement in pregnancy outcome after surgical treatment of mild endometriosis.111a The most widely used medical agents are danazol112,113 and gonadotropin-releasing hormone (GnRH) analogues.114,115 These agents are used alone for treatment of mild and moderate endometriosis, and in combination with surgery (both preoperative and postoperative) for treatment of these stages as well as severe endometriosis. The relative efficacies of these varied forms of treatment and the appropriate indications for concomitant therapy currently are unclear. An in-depth discussion of studies describing the medical and medical-surgical treatment of endometriosis is beyond the scope of this chapter; the reader is referred to published reports.111a, 112,113, 116,117,118
Pregnancy outcome after treatment is the most important end point for infertile couples; an assessment of outcome is given in Table 10.119,120,121,122,123,124,125,126,127,128,129,130 Considering the use of laparoscopy for reproductive pelvic surgery, more series have been described for the treatment of endometriosis than for other procedures. From the numbers in these reports (which are limited in part by lack of comparable life table analyses of outcome), it appears that, in experienced hands treatment at laparoscopy and at laparotomy are equally efficacious, not only for mild and moderate endometriosis but for severe and extensive endometriosis as well. This observation is consistent with a recent extensive meta-analysis of equivalent pregnancy outcome after treatment at laparoscopy and at laparotomy.130a Individual investigators131,132 have treated large endometriomas laparoscopically with high pregnancy rates resulting. In many series of laparoscopic treatments for endometriosis, the CO2 laser has been used.123,124,125,126,127,128,129 However, similar pregnancy rates obtained with nonlaser laparoscopic techniques have also been described.130 Other lasers that have been used for laparoscopic treatment of endometriosis are the argon,133 KPT-532,104 and Nd:YAG,134,135 types. Nevertheless, pregnancy outcome as an end point has its limitations, in that many factors can impair fertility after adequate treatment of endometriosis; furthermore, pregnancy can occur after inadequate treatment of endometriosis, and pregnancy can occur despite recurrence or persistence of endometriosis. Several investigators have tried to correct for other possible factors by looking at pregnancy outcome in women in whom endometriosis is the sole cause identified for infertility; slight improvements in pregnancy outcome have been identified.33
Endometriosis is noted to be present in 2% to 47% of women after surgical or medical treatment,136 the actual likelihood depending, in part, on the initial severity of endometriosis and the treatment undertaken. However, it has been difficult to differentiate recurrent from persistent endometriosis. Three types of reports suggest that persistence may be more likely than previously recognized. First, microscopic implants of endometriosis not visible to the naked eye (or to the eye with magnification) are frequently present.137,138,139 Second, many implants do not have the gross purplish macroscopic appearance that has become clinically recognized as endometriosis; they may be clear, yellow, red, or black, or they may be represented by converging vascular patterns or white scarring.140 Third, recognized implants of endometriosis may extend from the identified lesion beneath the peritoneum.141 For the latter, it has been suggested that visualized lesions be treated so as to include the immediately surrounding (normal-appearing) peritoneum. The actual surface area that should be treated, and whether such treatment affects rates of recurrence or persistence or pregnancy outcome, have not been established.
The extent of recurrence or persistence of endometriosis is best assessed at second-look laparoscopy; however, this requires performance of an additional operative procedure. Clearly, a nonoperative method of assessment would have tremendous advantages. A potential candidate is the serum marker is CA-125, a membrane antigen that is present in many conditions, including epithelial serous ovarian carcinoma.142,143 The antigen concentration is elevated in women with endometriosis, and initial studies suggest the level correlates with the severity of disease and with its clinical course.142,143 Another technique that has been evaluated is an endometrial antibody assay.144 Although only a small number of subjects were examined, the antibody level did appear to correlate with observations at second-look laparoscopy. Additional studies are required to further examine the potential of these markers.
Tubal Anastomosis and Implantation for Tubal Obstruction
An overview of pregnancy outcome after tubal anastomosis and tubal implantation procedures is shown in Table 11.145,146,147,148,149,150,151,152,153,154,155,156 Compared with other types of reproductive pelvic surgical procedures, pregnancy outcome is best after tubal anastomosis, approaching 70% in many series. Many factors affect the outcome of surgical procedures designed to re-establish tubal continuity, including the cause of the obstruction, its location, the extent of coexistent pelvic disease, the length of the resulting tube after patency is restored, and the length of time since tubal blockage.
Among women desiring reversal of previous tubal ligations, the method of tubal occlusion is a major prognostic factor in subsequent pregnancy outcome. The best results are obtained with Hulka clips or fallope rings; the worst outcome follows unipolar cautery, and intermediate pregnancy rates are achieved after segmental resection or bipolar cautery. These differences may be partially explained by the resultant length of tube after anastomosis, increasing tubal length correlating directly with improved pregnancy outcome. An additional factor may be the extent of damage to the tubal blood vessel arcade; both human and animal studies have suggested a possible role of this network in ovulation and pregnancy outcome. In tubocornual anastomosis, an additional advantageous prognostic factor is preservation of as much of the intramural segment of the fallopian tube as possible.149
The length of time between tubal ligation and reversal has been shown to be a prognostic factor, correlating inversely with subsequent pregnancy outcome. However, it is likely that this relation reflects the natural decline in fecundity with advancing maternal age, as opposed to an effect on the tubes per se.
DeCherney and coworkers10 examined the causes of failure to conceive in 35 women who underwent midsegment tubal anastomosis. A surgically related factor (bilateral tubal reocclusion) was noted in only 20% of these couples. In the remaining couples, ovulatory dysfunction was present, the husband had not previously fathered a child, or the infertility was unexplained.
Location of tubal occlusion is another major prognostic factor. Those women with tubal blockage that allows anastomosis to be performed generally have improved conception rates, compared with those requiring tubal implantation. In their in-depth review of surgical management of uterotubal obstruction, Musich and Behrman157 concluded that microsurgical anastomosis has replaced implantation as the primary method for re-establishment of tubal patency under most circumstances. Exceptions were surgeon preference and complete intramural occlusion. In a review of all series in the literature from 1965 to 1982 describing pregnancy outcome after uterotubal implantation and tubocornual anastomosis, Haseltine and Von Arras158 demonstrated improved pregnancy rates after anastomosis. Additionally, anastomosis obviates the decision of whether a conception occurring after a tubal implantation procedure should always be delivered by cesarean section and reduces the risk of uterine rupture at the site of implantation, a complication that has been described with the implantation technique.159
Women who have undergone fimbriectomy for sterilization represent a special category because the surgical correction required is a neosalpingostomy. In two small series of such women, pregnancy occurred in 57% (4/7)13 and 44% (4/9) of patients.160
Lasers have seen limited application in tubal anastomosis. Kelly and Roberts88 described excision of blocked tubal stumps with the use of a CO2 laser. It is unclear whether this procedure has any advantages over nonlaser techniques. Other investigators have attempted to anastomose the fallopian tube by “welding” with the CO2 laser but have noted this technique to be of little value.161
The feasibility of laparoscopic tubal anastomosis has now been demonstrated by Gray et al.205 It remains to be determined whether pregnancy outcome in such patients can approach the success observed at laparotomy.
|TUBAL ECTOPIC PREGNANCY|
The rate of occurrence of ectopic pregnancy has increased over the past several decades owing to alterations in sexual activity and perhaps to the advances in reproductive pelvic surgery. With regard to the latter, the ability to establish and maintain tubal patency in damaged tubes may allow conception to occur in women who previously would have been sterile, even though the extent of the tubal damage precludes (or reduces) the ability of the fertilized ovum to transgress the tube and reach the uterine cavity. Although this is only a theory, such a possibility is pertinent because of the issue of whether gamete intrafallopian transfer procedures should be performed on women with damaged but patent fallopian tubes. Currently, it is unclear whether such women are at an increased risk for a tubal ectopic pregnancy.
Once a tubal ectopic gestation is diagnosed or highly suspected, options for surgical therapy are whether to preserve or remove the fallopian tube and whether to perform the procedure at laparoscopy or at laparotomy. These decision are based on the location of the ectopic pregnancy and the extent of tubal damage. Cornual ectopic pregnancies are almost exclusively treated at laparotomy. Isthmic, ampullary, and infundibular ectopic pregnancies are more likely to be amenable to conservative management. Isthmic ectopic gestations are usually treated by segmental resection. Tubal ampullary and infundibular gestations can be treated by linear salpingostomy along the antimesenteric border. When the criteria listed in Table 12 are met, this procedure can be performed at laparoscopy, sparing the patient the increased morbidity associated with laparotomy. The safety of this procedure has been established by two large series describing its use.162,163 For a detailed description of these options, the reader is referred to published reviews.164,165,166,167 A summary of pregnancy outcome after treatment of ectopic pregnancies in selected series is shown in Table 13.168,169,170,171
Hemodynamically stable patient
Women who have had ectopic gestation have a 8% to 13% risk of a repeat ectopic gestation.169,172,173,174 This risk is independent of whether the initial ectopic pregnancy was treated conservatively or by salpingectomy. Among those treated conservatively, repeat ectopic gestation is equally likely to occur in the tube with the initial ectopic gestation as in the contralateral tube.175 This suggests that the processes that contributed to the initial ectopic pregnancy (whether pathologic disease or innate variants in tubal motility) are likely to affect each fallopian tube.
Among women with two prior ectopic pregnancies, the risk for a third ectopic gestation increases to 20%.176 Among those with an ectopic pregnancy in a sole remaining fallopian tube treated conservatively, the subsequent pregnancy rate ranges in most series from 32% to 60%, with a repeat ectopic pregnancy rate of 12% to 40%.162 Women who have undergone a segmental resection for treatment of an ectopic pregnancy and have a patent contralateral tube are at risk for development of a repeat ectopic pregnancy in the blind, ending distal segment of the partially resected tube.177
Medical treatment of ectopic pregnancy has been suggested as an alternative to surgical treatment,178,179 administered either systemically or by direct injection into the ectopic pregnancy. The chemotherapeutic agent most frequently used is methotrexate. This would appear to have its greatest utility when the ectopic gestation can not be localized or when surgical treatment has failed to eradicate all trophoblastic tissue. However, some centers use medical therapy as an alternative to surgical treatment.180 Patients treated in this fashion should be counseled regarding the need for serial β-human chorionic gonadotropin (β-hCG) titers, as well as the frequent description of increased pain after methotrexate administration, even when treatment is successful. To date, the greatest likelihood of failure with medical therapy appears to be in patients in whom a fetal heartbeat can be identified in the eccyesis.
Because of the risk of a persistent ectopic pregnancy after conservative treatment, patients should be monitored until the β-hCG level becomes negative. The term “persistent” ectopic pregnancy may mean different things to different investigators. Although some would include patients whose titers are falling slowly, we have reserved this term for patients with rising titers after initial therapy and those who become symptomatic, necessitating further intervention. Although an early series described no persistent ectopic pregnancies among 79 sequentially treated ampullary ectopic gestations,181,182 we have observed a rate of approximately 10%. The only two factors associated with persistent ectopic pregnancy that could be identified were smaller ectopic size and younger gestational age. It is unclear why the incidence of persistent ectopic pregnancy varied so greatly between these two reports. However, the second series was collected during a period when vaginal ultrasonography was used to exclude intrauterine pregnancies and identify tubal gestations. It is tempting to speculate that earlier identification of ectopic pregnancies by vaginal ultrasonography (and hence earlier treatment) was associated with a more viable eccyesis (i.e. less surrounding blood clot), with the result that surgical removal was less complete.
|OVARIAN WEDGE RESECTION|
Before the widespread availability of agents for induction of ovulation in women with polycystic ovary syndrome, ovarian wedge resection was a common method used to achieve ovulation. In theory, such a procedure reduced ovarian steroid production, temporarily allowing follicular development to resume. In one series, after wedge resection, resumption of ovulation occurred in 91% of the patients; however, subsequent conceptions occurred in only 48%.183
A potential cause for this discrepancy between ovulation and conception rates is the postoperative development of pelvic adhesions. Kistner184 noted peritubal and previous adhesions at culdoscopy in 16 women after wedge resection. Weinstein and Polishuk185 reported that 14% of women undergoing ovarian wedge resection and a subsequent second-look procedure developed pelvic adhesion. This number undoubtedly represents an underestimation, because only a selected group of nonpregnant patients underwent the second-look procedure. Buttram and Vaquero186 and Toaff and coworkers187 reported the presence of adhesions in 59 of 59 and 7 of 7 women, respectively.
A “pseudo-wedge resection” has been performed at laparoscopy in women with polycystic ovary syndrome.188 This procedure involved draining ovarian cysts with the use of electrocautery. Ovulation subsequently occurred in 57 (92%) of 62 women undergoing this technique. Of 35 women with polycystic ovary syndrome as the sole cause of infertility, conception occurred in 24 (69%) after electrocautery treatment. This procedure has also been performed with the use of the CO2 laser.104 As yet, no systematic assessments of postoperative adhesion formation after this technique have been performed, although Gjonnaess188 described their appearance in only one of six women in the initial series described above. However, the length of time that these women continue to ovulate spontaneously may be limited.
Fertility After Appendectomy and Cesarean Section
Two operations that women of reproductive age have frequently undergone are appendectomy and cesarean section. Several reports have examined the effects of these procedures on subsequent infertility. Trimbos-Kemper and associates189 noted a 42% incidence of tubal abnormalities among women who had undergone appendectomy; however, this was not statistically greater than the 37% incidence in the control group. Mueller and coworkers190 observed that women who underwent appendectomy with findings of an unruptured appendix were not at increased risk for infertility. However, those women with a ruptured appendix at the time of appendectomy were significantly more likely to be infertile.
Among American women who underwent cesarean section for their first childbirth, Hemminki and colleagues191 described a reduction in subsequent fertility, compared with controls. This reduction was attributed to physical difficulties related to the operation and potentially may have been caused by the cesarean section. Hemminki192 subsequently confirmed these findings in a report based on the Swedish Birth Registry, again demonstrating that women who undergo cesarean section have fewer children later.
|TREATMENT OF UTERINE PATHOLOGY|
A variety of congenital and acquired abnormalities of the uterus have been suggested as factors possibly contributing to the establishment of an infertile state. Several of these conditions and advances in their surgical management are described here. For a summary of uterine distention media used for hysteroscopy, the reader is referred to the review by Diamond and coworkers.193
Asherman's syndrome is the presence of adhesions within the uterine cavity. The most common cause is infection after curettage of a pregnant or recently pregnant uterus. Such adhesions partially or completely obliterate the uterine cavity and are diagnosed by hysteroscopy, hysterosalpingography, or both. Obliteration of the uterine cavity by adhesions causes amenorrhea in its most severe forms and is a contributing factor to infertility. Among those women with intrauterine adhesions who are able to conceive, only a small percentage are able to carry the pregnancy to term; this percentage increases markedly after lysis of the intrauterine adhesions.194,195 Treatment of these adhesions currently is at the time of hysteroscopy. Although lysis can be performed bluntly with the hysteroscope, adhesions in the noncentral sections of the uterine cavity may be missed; alternative therapy is by dilatation and curettage of the uterus or with hysteroscopic scissors, electrosurgery, or lasers. Pregnancy outcome after surgical treatment of Asherman's syndrome is shown in Table 14.196,197,198,199 Relative efficacies of the various methods of lysing the intrauterine adhesions has not been examined.
*Term or ongoing
At the completion of these operative procedures, particularly with more extensive adhesions, either an intrauterine device or a pediatric Foley catheter is placed in the uterine cavity. This reduces the apposition of the anterior and posterior uterine walls, thereby reducing redevelopment of adhesions. Most reports also describe administration of estrogen to these patients.
Removal of a uterine septum has traditionally been performed at laparotomy by either the Jones or the Tompkins technique. The rationale for performance of this operative procedure is that the septum might contribute to infertility or early miscarriage if the embryo were to “implant” on it; poor survival is attributed to inadequate blood supply to the uterine septum.200
Although such elimination of the septum reduces the likelihood that a pregnancy will miscarry, it is likely that adhesions that develop as a result of such procedures reduce the actual conception rate. Therefore, before a metroplasty at laparotomy is performed, women have been given the opportunity to conceive and carry pregnancies. Additionally, because infertility is rarely caused by uterine anomalies alone,201 these couples should undergo the same rigorous evaluation as infertile couples without uterine anomalies.
Several groups have described the performance of hysteroscopic “metroplasties.”202 These procedures involve incision of the septum and have been performed with hysteroscopic scissors, resectoscope, and the Nd:YAG laser. The procedures are performed concomitantly with laparoscopy, so that if uterine perforation does occur, it can be identified immediately and damage to pelvic structures can be minimized. Although difficulties identifying both cavities may occur, complications in experienced hands have been minimal. Pregnancy rates with these techniques or abdominal metroplasty are listed in Table 15 and appear to be similar to the success rates after conventional metroplasty.203,204,205,206,207,208,209,210,211,212,213 Additionally, the hysteroscopic procedures can be done on an outpatient basis, without the morbidity associated with laparotomy. In a report comparing outcomes in one center, Fayez206 compared abdominal and hysteroscopic metroplasties and observed no significant difference in results at postoperative hysterosalpingography or in subsequent pregnancy outcome. However, hysteroscopic procedures were associated with decreased operating time, less blood loss, and shorter hospitalization. For these reasons, many have concluded that it is reasonable to perform prophylactic hysteroscopic “metroplasties” in women undergoing infertility evaluations, before assessing whether conception occurs and pregnancy outcome after conception.
Uterine fibroids are a frequent finding, and they occur with increased frequency in older women prior to menopause. Although uterine fibroids are a recognized cause of pregnancy loss,214,215 as a general rule they are considered to be a rare cause of infertility.215 However, in specific circumstances they may contribute to infertility, as when fibroids cause tubal occlusion at the cornua of fill the uterine cavity or when gestations try to implant in endometrium overlying a fibroid. In the latter case, impaired blood flow to the implantation site could prevent successful nidation. For an in-depth review of myomas, reproductive function, and pregnancy outcome, the reader is referred to the summary by Rossi and Diamond.216
Despite the general consensus that myomas rarely cause infertility, conception rates after myomectomy average approximately 50% (Table 16).217,218,219,220,221,222 This apparent paradox can perhaps be explained by concomitant treatment of other tuboperitoneal disease at the time of myomectomy (e.g. endometriosis, tubal obstruction, pelvic adhesions). In fact, Berkeley and colleagues217 noted conception in only one (16%) of six women with myoma but no other infertility factors. Assessment of the use of the CO2 laser in abdominal myomectomy has been limited. McLaughlin220 noted a subsequent pregnancy rate of 33% and described a reduction of approximately one third in blood loss with the CO2 laser, compared with nonlaser technique.
Many surgeons have begun to treat uterine myomas at laparoscopy.223 Pedunculated myomas are often easy to excise from the uterus but can be difficult to remove from the abdominal cavity if they are large. Options include morcellation, posterior colpotomy, and, more recently, minilaparotomy. It remains to be shown whether there are overriding advantages of these options, particularly the minilaparotomy, compared with initial performance of a myomectomy at laparotomy. Even more controversial is the laparoscopic treatment of subserosal or intramural myomas that do not impinge on the uterine cavity. First is the question of why these myomas need to be excised. Second is the question of whether the integrity of the uterine myometrium wall can be adequately established by laparoscopic closure and of the extent of postoperative adhesion development. The latter issue causes particular concern because of the report of a 25% (6/24) incidence of fistulas between the uterine cavity and the abdominal cavity after laparoscopic myomectomies.224
A potential complication of abdominal myomectomy is the postoperative development of pelvic adhesions, with associated effects on fertility. Neu-wirth221,222 described hysteroscopic resection of submucous uterine fibroids with subsequent pregnancy in 8 of 28 women. The hysteroscopic procedure, in experienced hands, has the theoretical advantages of reduced hospitalization, operative morbidity, consideration of cesarean section for delivery, and development of postoperative pelvic adhesions. However, it does not allow removal of nonsubmucosal fibroids. The latter factor is potentially important because the rate of symptomatic recurrence of myoma has been reported to be 27% in women with isolated myoma and 59% in those with multiple myomas.225 In part, the recurrence rate probably varies with the diligence of the surgeon in removing “seedling” myomas at the initial operative procedure.
GnRH analogues have also been used to treat uterine leiomyoma. Although these agents have been successful in reducing the size of the myoma during administration, cessation of treatment has been associated with re-enlargement.226,227 The analogues have been used in conjunction with surgery to achieve preoperative shrinkage. However, the frequency with which this approach truly enhances the ease of surgery has not been established; some surgeons believe that the myoma capsule is less well defined after GnRH therapy, thereby making the surgery more difficult. One advantage of GnRH pretreatment is the reduction of blood loss; however, it is unclear whether this effect is clinically significant. In anemic patients, GnRH analogues may be used successfully as a temporizing measure to postpone the surgery, allowing the patient to build up her blood count and to donate autologous blood for transfusion should it become necessary. However, myomectomies are infrequently complicated by either large-volume hemorrhage requiring heterologous transfusion or the need to convert to an undesired hysterectomy.228
One additional consideration regarding the use of GnRH analogues in women with uterine fibroids is that the lesion may actually be a leiomyosarcoma. This is a rare occurrence, but it can be suggested by myomas that fail to shrink in size or actually enlarge during GnRH therapy.229,230 If a leiomyosarcoma is present, it is usually (95% of the time) the only or the largest myoma present.230 Finally, it appears that GnRH therapy should not significantly alter the ability of the pathologist to differentiate a benign myoma from a malignant leiomyosarcoma.231
The literature includes a series of reports describing restoration of tubal patency in women with such procedures as transposition of the fallopian tube or anastomosis of one segment of the fallopian tube to the other.232,233,234,235,236 Although pregnancies have been achieved in some of these reports, it is not possible to assess what the pregnancy rate would be in large groups of women undergoing such procedures. Three reports in the literature describe transplantation of human fallopian tube into another woman. In all, a dozen attempts have been made, but no pregnancies have been achieved.237,238,239 Transplantation of the ovaries and fallopian tubes before pelvic radiation for an aneurysmal bone cyst has been performed with subsequent replantation after completion of therapy.240 Conception did occur, but preterm labor developed and a preterm, stillborn male infant was delivered.
Therefore, although there may remain a use for such procedures in individual cases, their efficacy in view of available in vitro fertilization techniques must be evaluated.
Vaginal and Cervical Procedures
Surgical correction of vaginal obstruction is associated with high success rates. Rock and coworkers241 noted that 13 of 15 women who were trying to conceive did so after correction of an imperforated hymen, whereas 9 of 19 women attempting to conceive after surgical treatment of a transverse vaginal septum were able to do so. Among the women with transverse vaginal septum, six of seven in whom laparotomy was performed were noted to have endometriosis. The authors suggest that prompt diagnosis of vaginal obstruction in these women may be important to minimize impairment of fertility by endometriosis.
Cervical conization as treatment for cervical dysplasia is not thought to significantly reduce fertility.242 However, the need to individualize the cone to the existing cervical pathology has been emphasized so as to keep this risk to a minimum.242 Although cervical stenosis after conization is rare, it does occur.243 There is one report of reconstruction of the cervical canal after complete postconization obstruction with the use of a combined vaginal and abdominal approach.244
The term pelviscopic surgery refers to extensive operative laparoscopic procedures involving the use of sutures, Roeder loops, and other laparoscopic instrumentation. The procedures allow laparo-scopic excision of tubal ectopic gestations, ovaries, and tubes, as well as entire adnexa. This technique was pioneered by Semm245,246 and has been extended by many surgeons in the United States.130,247,248,249,250,251 Such techniques have great potential in view of their ability to reduce the morbidity and expense associated with laparotomy; however, they require sophisticated instrumentation and an experienced operative laparoscopist. Additionally, although it was initially demonstrated that laparoscopic procedures were less expensive than the same procedure performed at laparotomy248 (with the savings primarily attributable to a reduction in the length of hospital stay and its associated costs), more recent procedures, in which disposable instruments were used, have generated higher costs. Therefore, ongoing evaluation is needed to assess safety and efficacy.
|ALTERNATIVES TO SURGICAL TREATMENT|
With the introduction of ART, an alternative to surgery for the treatment of tuboperitoneal disease now exists. The difficulty lies in deciding the risk-benefit ratio for in vitro fertilization (IVF) as opposed to corrective surgical procedures. This is an issue that continues to be addressed, and one for which the answers will change as the success rate, risks, and morbidity of each choice are altered by technological advances. Additionally, the important issue is not the optimal outcome available at leading centers, but the likely outcome where the procedure is to be performed.
The issue of when to refer patients for IVF is beginning to be addressed. Mage and associates252 reviewed the pregnancy outcome after surgery for distal tubal obstruction. Outcome was predicted based on tubal patency, the appearance of the ampullary tubal mucosa, the ampullary tubal wall thickness, and the presence and types of pelvic adhesions. It was recommended that women with more extensive tubal damage or severe adhesions be referred for IVF because of the low intrauterine pregnancy rate and the observation that conceptions that did occur were more likely to be ectopic than intrauterine. Failure to achieve pregnancy among patients with more severe pelvic adhesions has also been identified by the Intraabdominal Laser Adhesion Study Group.253
An issue that has been raised is whether a second tuboplasty should be performed for the treatment of tuboperitoneal disease, or whether such a patient should be referred for IVF. (Excluded from what would be considered the first tuboplasty would be performance of an appendectomy, treatment of an ectopic pregnancy, excision of an ovarian cyst, and other procedures in which the intent was not the performance of reparative tubal surgery.) There are few studies in the literature that address this issue; their outcomes are listed in Table 17.254,255,256 Term pregnancy outcome ranged from 8% to 32%, a range not dissimilar from that seen with IVF in many centers. Therefore, a plausible role for repeat tuboplasties may remain. Potentially, the benefit of repeat tuboplasty may be greater if it can be performed at laparoscopy. Even with the use of a multipuncture technique, the morbidity of such a procedure in experienced hands would be less than that associated with laparotomy.
Another issue raised is whether women with bipolar tubal disease should undergo tuboplasty or be referred for IVF. As shown in Table 18, reports describing pregnancy outcome after treatment of bipolar disease are also limited.257 However, 34% of the women in these studies were able to deliver a term pregnancy. Therefore, for each of these questions, it remains for studies to be performed to assess the relative efficacy of surgical versus IVF approaches.
In IVF programs, oocytes are now routinely recovered by laparoscopy and ultrasound-guided aspiration. When most oocyte recovery was by laparoscopy, it was suggested that women with tuboperitoneal disease might benefit from operative procedures to “prepare” the pelvis for IVF, including possible salpingectomies, adhesiolysis, and ovarian suspensions.37,258,259,260 However, the rapid development of ultrasound-guided aspiration techniques has obviated this procedure as a means of providing ovarian access. The consideration that remains is whether such adhesions impair follicular development in response to exogenous stimulation, as suggested by Mahadevan and colleagues.136 In a subsequent report examining this issue, such a relationship was not observed.261 Therefore, there no longer appears to be a reason to perform pre-IVF laparotomies or laparoscopies to “prepare” the pelvis for oocyte recovery.
|COMPLICATIONS OF ENDOSCOPIC SURGICAL PROCEDURES|
The excitement regarding increased endoscopic surgical procedures for treatment of infertility has progressed until recently with relatively little attention to the issue of operative complications and their management. As an example, when we had a patient with ureteral injury, an initial review of the literature yielded no prior reports of this occurrence.262 Eventually, we were able to identify a handful of previously reported cases, and included several other recent cases that had completed litigation to produce a series of five patients. However, in discussing this complication with groups of colleagues, we found that almost all groups had at least one member who had personally experienced this complication or was aware of a similar complication experienced by a physician in their community, indicating this and other complications are occurring but being underreported. As a consequence, surgeons may be less likely to avoid similar recurrences. For a more in-depth review of complications, their identification, management, and avoidance, the reader is referred to a recent publication.263
Two categories of challenges confront the gynecologic surgeon. The first is to examine the previous success of surgical treatment of tuboperitoneal disease and intrauterine lesions and to compare these results with the efficacy and safety of new innovations in regard to both operative approach (e.g. endoscopy versus laparotomy) and instrumentation (e.g. lasers, operative laparoscopies, hysteroscopies). Additionally, the efficacy of these innovations must be compared with that of nonsurgical means of treatment, namely medical therapy (e.g. danazol and GnRH analogues for endometriosis, methotrexate for ectopic pregnancies) or use of gamete and embryo transfer techniques (e.g. IVF, gamete intrafallopian transfer). The second challenge is to recognize specific areas in which improvement is needed and to develop approaches, devices, drugs, and instruments necessary to overcome them. Such areas include maximizing pregnancy outcome, preventing postoperative adhesion development, identifying accurate, noninvasive methods of assessing intraperitoneal endometriosis and adhesions, and continuing to reduce the operative morbidity associated with gynecologic surgery.
22. Kelly RW, Diamond MP: Intra-abdominal use of the carbon dioxide laser for microsurgery. In Dorsey J (ed): Laser Surgery in Obstetrics and Gynecology Clinics of North America, pp 537–544. Philadelphia: WB Saunders, 1991
33. Hulka JF: Adnexal adhesions: A prognostic staging and classification system based on a five-year survey of fertility surgery results at Chapel Hill, North Carolina. Am J Obstet Gynecol 144: 141, 1982
47. Diamond MP, Daniell JF, Martin DC et al: Tubal patency and pelvic adhesions at early second-look laparoscopy following intra-abdominal use of the carbon dioxide laser: Initial report of the intra-abdominal laser study group. Fertil Steril 42: 717, 1984
58. LaMorte AI, Diamond MP: Adhesion formation: Laparoscopic surgery. In Diamond MP, DiZerega GS, Linsky CB et al (eds): Gynecologic Surgery and Adhesion Prevention, pp 51–58. New York: Wiley-Liss, 1993
59. Guerre E Jr, Diamond MP: Adhesion prevention: Does anything work? In Johns DA (ed): Controversies in endoscopy. Infertility and Reproductive Endocrinology Clinics of North America. Philadelphia: WB Saunders Co, 1993
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80b. Diamond MP and the Seprafilm Adhesion Study Group: Reduction of adhesions after uterine myomectomy by Seprafilm (HAL-F): A blinded, prospective, randomized, multicenter clinical study. Fertil Steril 66:904–910, 1996
80c. Diamond MP and the Seprafilm Adhesion Study Group: Reduction of de novo postsurgical adhesions by intraoperative precoating with Sepracoat (HAL-C) solution: A prospective, randomized, blinded placebo-controlled multicenter study. Fertil Steril 69:1067–1073, 1998
99. Kerin J, Daykhovsky L, Grundfest W et al: Falloscopy, a microendoscopic transvaginal technique for diagnosing and treating endotubal disease incorporating guide wire cannulation and direct balloon tuboplasty. J Reprod Med 35: 606, 1990
114. Meldrum DR, Padridge WM, Karow WG et al: Hormonal effects of danazol and medical oophorectomy in endometriosis. Obstet Gynecol 62: 480, 1983
119. Rock JA, Guzick DS, Sengos C et al: The conservative surgical treatment of endometriosis: Evaluation of pregnancy success with respect to the extent of disease as categorized using contemporary classification systems. Fertil Steril 35: 131, 1981
123. Daniell JF: Combined laparoscopic surgery and danazol therapy for pelvic endometriosis. Fertil Steril 35: 521, 1981
124. Kelly RW, Roberts DK: CO2 laser laparoscopy: A potential alternative to danazol in the treatment of stage I and II endometriosis. J Reprod Med 28: 638, 1983
130a. Shamma FN, Diamond MP: Postoperative adhesion development after operative laparoscopy: Evaluation at early second-look procedures. In Adamson D, Martin D (eds): An Atlas of Endoscopic Management of Gynecologic Disease. Philadelphia: Lippincott Raven Publishers, 1996
136. Mahadevan MM, Wiseman D, Leader A et al: The effects of ovarian adhesive disease upon follicular development in cycles of controlled stimulation for in vitro fertilization. Fertil Steril 44: 489, 1985
151. Diamond MP, Christianson CD, Daniell JF: Microsurgical reanastomosis of the fallopian tubes: Increasing successful outcome for reversal of previous sterilization procedures. South Med J 75: 443, 1982
196. Taylor PJ, Cumming DC, Hill PJ: Significance of intrauterine adhesions detected hysteroscopically in eumenorrheic infertile women and role of antecedent curettage in their formation. Am J Obstet Gynecol 139: 239, 1981
226. Maheux R, Guilloteau C, Lemay A et al: Regression of leiomyomata uteri following hypoestrogenism induced by repetitive luteinizing hormone-releasing hormone agonist treatment: Preliminary report. Fertil Steril 42: 644, 1984
253. Diamond MP, Martin DC, Feste J et al: Pregnancy outcome following adhesiolysis at laparotomy and subsequent early second-look laparoscopy [Abstract]. 15th Annual Meeting, Clinical Symposium of Gynecologic Endoscopy, Orlando, FL, November 1986
261. Diamond MP, Pellicer A, Boyers SP et al: The effects of periovarian adhesions on follicular development in patients undergoing ovarian stimulation for in vitro fertilization embryo transfer [Abstract]., 43rd Annual Meeting of the American Fertility Society, Reno, NV, September 1987